Provider Demographics
NPI:1497465561
Name:BAUER, SAMUEL GREGORY (PSYD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GREGORY
Last Name:BAUER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 BROADWAY RM 1510
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-3368
Mailing Address - Country:US
Mailing Address - Phone:212-262-2850
Mailing Address - Fax:
Practice Address - Street 1:1430 BROADWAY RM 1510
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-3368
Practice Address - Country:US
Practice Address - Phone:212-262-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty